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Confidential Personal Financial Statement

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Personal Information

Name:

SSN:

Address:

Birthdate:

City, State, Zip:

Dependents:

Home Phone:

Business Phone:

Section I: Assets & Liabilities

ASSETS
1. Cash on Hand & Banks:
2. Cash Value Life Insurance:
3. U.S. Gov. Securities:
4. Marketable Securities:
5. Notes/Accounts Rec. (Good):
11. Real Estate Owned:
16. Personal Property:
TOTAL ASSETS:

LIABILITIES
21. Notes Due to Banks:
22. Notes to Relatives/Friends:
24. Accounts/Bills Payable:
25. Unpaid Income Tax:
34. Real Estate Mortgages:
35. Liens/Assessments:
TOTAL LIABILITIES:

Annual Income & Expenses

Salary/Commissions:
Other Person's Salary:
Rental/Lease Income:
Other Income (Itemize):

Income Taxes:
Insurance Premiums:
Mortgage/Rent:
Other Expenses:

Section II: Itemized Schedules

E. REAL ESTATE: (Title, Location, Date Acquired, Cost, Market Value, Insurance, Mortgage Balance, Maturity, To Whom Payable)

B. LIFE INSURANCE: (Company, Beneficiary, Face Value, Cash Value, Policy Loans)

C. SECURITIES: (Shares, Stock Type, Ownership, Cost, Market Value)

General Information

Are any assets pledged? Yes No
Defendant in any legal actions? Yes No
Declared bankrupt in last 10 years? Yes No
Explain (if Yes):

For the purpose of procuring credit from time to time, I/We furnish the foregoing as a true and accurate statement of my/our financial condition. Authorization is hereby given to verify any and all items indicated. The undersigned also agrees to notify Caryn Isaacs immediately in writing of any significant adverse change in such financial condition.

Signature: Date: